Archive for the ‘BMJ’ Category

The first salvo in the Guardian’s recently published series of articles on academic publishing was delivered by veteran agitator George Monbiot. Journals publish government funded research, written and often edited for free by academics says Monbiot. “But to see it, we must pay again, and through the nose” he says.

The monopolist practices of academic publishers make Walmart ‘look like a corner shop’ and Rupert Murdoch ‘look like a socialist’ he continues.

In a second article Ben Goldacre writes of Aaron Swartz, a digital activist. Swartz is accused of downloading academic papers on a grand scale, intending to make them available for free on file sharing sites such as Pirate Bay. Goldacre writes that in some respects this is a remarkable tale of “Robin Hood behaviour”.

Thirdly David Colquhoun writes of the enormous pressure on academics to publish research papers. He says this has lead to a proliferation of journals and a shortage of qualified peer reviewers. As a result the quality of published research has nosedived. “The only people who benefit from the intense pressure to publish are those in the publishing industry” he writes.

Profits for some academic publishers certainly are healthy. Monbiot reports that Elsevier made £724m on revenues of £2bn during the last financial year. This is a profit margin of about 40%. Can this be justified?

In the past Reed Elsevier has defended their profits on the basis of their skilled staff, their support to authors and peer review panels, and their complex typesetting and distribution costs.

“We believe the publisher adds relatively little value to the publishing process. We are not attempting to dismiss what 7,000 people at REL do for a living. We are simply observing that if the process really were as complex, costly and value-added as the publishers protest that it is, 40% margins wouldn’t be available.”

The industry does face major challenges. Libraries are struggling to pay escalating subscription prices and electronic distribution of papers is making the established business model redundant.

Open access is an alternative paradigm, where authors pay a publishing fee to make journal articles are free for anyone to access.

In 2008 the BMJ formally became an open access journal and all BMJ research articles are free to access immediately upon publication.Authors are asked to pay a publication fee per accepted research article if their research grant covered open access publication fees.Other ‘added value’ articles, such as clinical reviews or editorials, require a subscription.In addition to the BMJ, BMJ Open is an online only open access journal also owned by the BMJ group.

A further option is self archiving, where freely accessible copies of an article are placed on the web.In his article Colquhoun favours a variety of this approach with peer review provided through anonymous reader comments.

Newspaper models

With ten daily national newspapers, the UK has one of the most competitive newspaper markets in the world. Since the 1980s sales have fallen but innovative business models are emerging which may have lessons for academic publishing.

The Guardian has long championed a comprehensive free online presence. Although its website does provide a substantial income from advertising, the newspaper remains unprofitable and is famously underwritten by the less sophisticated Autotrader, a trading magazine for used vehicles, also owned by the Scott Trust.

By contrast the Times does not allow any of its articles to be read online for free. When introduced this move lead to a drastic drop in online traffic. Whist dismaying to columnists, News Corp may not be concerned about this drop as occasional visitors tend to ignore ads and add little value. The Times has concentrated on maximizing business from loyal readers; the site is awash with advertisements for tie-ins such as wine clubs and holidays.

The Daily Mail has the world’s second biggest newspaper website, with 35m unique visitors per month. Unlike the alarmist print edition, the online Mail focuses on the fashion choices of attractive female celebrities.

Innovation is not restricted to online approaches. The Evening Standard print edition is now entirely free, and its circulation has doubled. Distribution costs have also fallen. The paper is handed out at Underground stations and each issue is read multiple times as abandoned copies are moved around London by Tube. It’s still not in profit, but its losses have halved.

The Independent’s approach is arguably the most experimental. It has introduced an abridged version called ‘i’, which is distributed alongside the full newspaper. The greater combined distribution of these two offerings makes selling advertising easier.

Lessons?

The approaches of UK newspapers indicate that new business models for academic publishing can include both print and online innovation. Approaches such as those of the Mail may of course not be compatible with the brand values of academic journals. Allowing increased free access will appease critics such as Monbiot and augment readership, but may not encourage loyalty. A closed model, like that of the Times, prevents bloggers linking to the research they discuss, potentially decreasing a paper’s impact.

It will be dangerous for academic publishers to do nothing. In his article Goldacre suggests a grubby compromise may emerge. Journals will stay afloat financially due to institutional subscriptions, whilst individuals will avoid excessive per article charges by downloading articles they wish to see from semi-legal content sharing sites. I expect that this is not a situation most publishers would welcome. “These are very interesting times for information” he writes. I agree.

(June 2018 review – things have moved on quite a bit since I wrote this, although academic publishing is still going strong. The Guardian no longer owns Auto Trader. The Independent Newspaper became online only in 2016. Aaron Swartz committed suicide in 2013 aged 26. Sci-hub allows academic papers to be accessed without a paywall and in 2015 was prosecuted by Elsevier. )

The RSM’s Global health and human rights film club launched on 8 September 2011 with a screening of director Mark Hopkins’ Living in Emergency.

Filmed in the war-zones of Liberia and Congo it follows four volunteer doctors providing emergency care under the aegis of Doctors Without Borders/Médecins Sans Frontières (MSF). The film’s urgent title is borne out by its content. The doctors work in chaotic overcrowded clinics, there is limited diagnostic equipment and often they have sole responsibility for the lives of all the patients they treat.

The stress of this situation runs through every frame and every line of dialogue. “The demand is pretty much infinite” says Dr Christopher Brasher. “It’s just a matter of choosing what you can do”. The film shows that the inadequacy of what MSF’s doctors can offer is in direct contrast to the enormity of the task with which they are faced.

Brasher, a veteran of several conflicts, wants out but wonders where he should now call home. American surgeon Tom Krueger works in Monrovia’s only emergency hospital and is on his first assignment, having grown disillusioned with the contribution he could make at home. He appears to cope the best, but struggles to live with his inevitable mistakes.

Davinder Gill, 26 years old and working in remote bush, is overwhelmed and exhausted by his responsibilities. His irascibility makes him the most compelling character, his frustrations leaving him unguarded in front of the camera. Perhaps inevitably Chiara Lepora, the head of the Liberia mission, compares him to Conrad’s Kurtz, driven mad by the insanity that surrounds him. Like the majority of MSF doctors who never make it beyond one 9 month mission, Gill is unlikely to volunteer for a second time.

When conflicts end, healthcare needs remain and the film sensitively shows how difficult it is to leave. Also here are the gore, personal conflicts, and difficult compromises that day to day MSF work entails. This is no recruitment film for MSF, but a forceful character study of people close to their emotional limit.

It’s a shame that couldn’t have gone a bit deeper, as its subjects’ back stories remain untouched. A more serious omission is total lack of any local viewpoint on MSF interventions or volunteers. Without this, their suffering becomes a mere backdrop for the disillusionment of Western idealists.

Metaphors are widely used by both healthcare professionals and lay people when talking about matters of health. Despite this their role is largely unrecognised. This is a shame, I feel, as they can have a powerful effect on the practice of medicine and the experience of illness.

A metaphor is a way of understanding and experiencing one kind of thing in terms of another. Many complex concepts are understood in this way and they are integral to the way we understand things.

The essayist Susan Sontag was one of the first to identify the widespread use of metaphor in relation to certain diseases. She wrote Illness as Metaphor whilst being treated for breast cancer and visited the topic again in 1988 with AIDS and its metaphors.

Sontag argued that metaphors attach themselves to certain diseases and these metaphors exert influence on patient and public attitudes. With both HIV and cancer Sontag argued that metaphors introduced an unhelpful emotional dimension when a more detached scientific approach was required.

Two main sorts of metaphors have been suggested. “Biomilitary” metaphors represent disease and the body’s response to it in terms of “attack” and “defence.” By contrast with “bioinformationist” metaphors the body, in both health and disease, is seen as a communication system with “receptors,” “transmitters” etc.

Particular diseases attract metaphorical description more readily than others. Biomilitary metaphors are pervasive in discussions of cancer. By contrast heart disease is discussed almost exclusively in terms of the mechanical metaphor of plumbing.

Arguably metaphors don’t merely describe similarities; they create them. As well as illuminating they can also conceal. It can be hard to think of cancer in a way that is not biomilitary, but wars honour battles which can make the transition to hospice care problematic. Mechanical metaphors for heart disease are also limited as they hold no place for lifestyle modification. I don’t agree with Sontag that metaphor should be eliminated from the discussion of medical illness. In fact I don’t actually believe that it would be possible to talk about disease without them. But they have a hidden power that should be understood.

Last Wednesday I joined the BMJ as the Roger Robinson editorial registrar. This is my first despatch from the frontline of medical publishing.

The registrar role has been running for 22 years and is named after the late Professor Robinson who was an associate editor at the BMJ for ten years. It’s for one year and allows the post holder to take a break from clinical practice and develop skills in medical journalism and editing. This sounded like an excellent opportunity to me as I’ve been interested in writing and publishing since medical school.

Although I’ve been in the job less than a week, I’ve already been put to work and have written my first news article. In the process I’ve learnt that news requires short paragraphs and quotes are vital to lend a sense of currency. BMJ style strongly discourages the passive voice. I also helped select letters from amongst the BMJ’s many rapid responses for inclusion in the upcoming issue.

I’ve not worked in an office for over ten years and there are lots of differences to my previous NHS foot soldier job. Clearly I’m not seeing any patients at the moment, which is a shock. Another big change is how central the BMJ’s offices are – I’m used to working in the far reaches of the capital (where the riots are). It’s not been a complete culture change though, as amongst many medical journalists there are also plenty of medically trained staff. I find it quite exotic that a lot of people at the BMJ work remotely, some as far away as Sydney and Boston USA. At any meeting several people join us by phone.

I’ll save further details of how the journal is put together for future despatches. As a final reflection, unlike stereotypical journalists I detect no evidence of a habitual heavy drinking culture here, but the coffee in the canteen is tasty, keenly priced, and frequently very strong.